Failure to follow diabetes management orders was identified for two residents. One resident with type 2 DM and hyperglycemia had multiple blank MAR/TAR entries for Trulicity, Lantus, and BG checks, while another resident had blank entries for Humalog, insulin glargine, and insulin lispro. No chart codes or follow-up codes showed whether the meds or monitoring were completed, and the DON confirmed staff did not document administration or follow up when insulin was omitted.
Failure to maintain function and provide scheduled bathing. A resident reported decline after therapy ended, with staff no longer using the sit-to-stand lift and instead using a full body lift, which changed toileting from the toilet to a bed pan and coincided with increased incontinence and reduced self-care abilities. Facility staff confirmed there was no restorative nursing program. The same resident also reported wanting two baths weekly but often receiving only one or none; the care plan did not reflect the updated preference, documentation showed only weekly bathing, and staff confirmed a missed bath due to staffing issues and that the resident had gone more than a week without a bath.
A resident with osteomyelitis, DM2, and a foot ulcer was ordered IV ampicillin/sulbactam and wound care, but received the wrong IV antibiotic, ertapenem, instead. A physician order required the ID doctor to be notified of the med error, but RN, RCM, LPN, and the Adm confirmed ID was not notified and the order was not followed.
A cognitively intact resident with DM received scheduled Humalog and Lantus, but the record showed repeated Humalog refusals and held doses, with many refusals lacking a documented reason. The chart contained no evidence that the resident was educated about refusing insulin or that the MD was updated about the ongoing refusals; the MDS Coordinator, DON, and Administrator confirmed the facility lacked a policy for insulin refusal and physician notification.
Failure to Notify Provider of Abnormal BP Readings The facility did not notify the provider when a resident’s BP was outside ordered parameters. One resident with HTN, stroke history, and repeated falls had many BP readings above the ordered limits over several months, with no documentation of provider notification. Two other residents with HTN also had BP readings below ordered limits, including low readings during med pass, and their records likewise showed no evidence that the provider was notified.
Failure to provide ordered bowel care interventions for a resident with constipation and severe cognitive impairment. The resident had PRN bowel meds ordered, and the facility's bowel management guideline required escalating interventions when no BM occurred, but the bowel task record and MAR showed no bowel interventions were given during four consecutive days without a BM. An LPN and the COD confirmed the resident did not receive bowel management interventions during that period.
A resident with chronic wounds, severe obesity, lower leg swelling, and HTN did not receive ordered wound care on multiple occasions, and PRN Clonidine was not administered for repeated systolic BP readings above the ordered threshold. An LPN confirmed the missed treatments and medication doses were not completed as ordered, and the DON confirmed staff did not follow the provider orders or facility policy.
A facility failed to complete glucometer QC testing when new test strip bottles were opened for two residents, and staff confirmed the required control solution entries were missing from the log. The facility also failed to follow PICC dressing-change technique for a resident, with the RN using nonsterile handling steps and contaminating concerns during the procedure. In addition, the RN did not flush both PICC lumens as ordered and the resident’s MAR order for IV Unasyn lacked key administration details such as the infusion amount, duration, and rate.
The facility failed to carry out multiple provider orders for a resident with CKD, pulmonary issues, and an indwelling catheter, including ordered BMP testing and IV LR, and the resident later had a critically high creatinine and was sent to the ER. The facility also missed or delayed routine labs for other residents, including CBC, CMP, TSH, Vitamin D, and UA testing, with some orders not completed until days or months later.
A resident with a CVA-related hemiplegia sustained a fall with left ankle pain and later was found to have an ankle fracture, but the record did not show a follow-up injury assessment, timely x-ray result retrieval, or an orthopedic appt being scheduled. In addition, two residents with significant mobility and continence needs had missing weekly skin/wound observations over multiple weeks, despite staff and policy stating these assessments were to be completed weekly.
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